Provider Demographics
NPI:1336627017
Name:RADEMACHER, JACKIE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:RADEMACHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11870 MARKET AVE
Mailing Address - Street 2:
Mailing Address - City:COLOGNE
Mailing Address - State:MN
Mailing Address - Zip Code:55322-9043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11870 MARKET AVE
Practice Address - Street 2:
Practice Address - City:COLOGNE
Practice Address - State:MN
Practice Address - Zip Code:55322-9043
Practice Address - Country:US
Practice Address - Phone:415-989-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-03
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician